Content warning: baby loss, death.
In June, the largest maternity review in NHS history, which investigated Nottingham’s maternity services, was finally published. Led by senior midwife Donna Ockenden, it examined 2,536 cases of mothers and babies who died or were harmed under the care of Nottingham University Hospitals NHS Trust between 2012 and 2025, during pregnancy, childbirth, or the weeks after birth. The review, which also heard from more than 830 current or former NUH staff, revealed that more than 500 mothers and babies were harmed or died as a result of inadequate care. Behind each number is a future grieved and an entire family that will never be the same again. People were utterly failed, often repeatedly, by the services that were supposed to care for them in some of their most vulnerable moments. In many cases, they were then blamed, gaslit and lied to.
The report uncovered that a “bullying and toxic culture” persisted at Queen’s Medical Centre and Nottingham City Hospital over many years, hindering efforts to improve care; that senior leaders were repeatedly warned about serious problems by concerned members of staff but did not take effective action; and that maternity staff showed “a culture of not admitting women who were seeking admission in labour”. Both maternity units were consistently short-staffed and could not cope with the number of births and the complexity of cases they had to handle. Perhaps most shockingly, the report found that even in cases of death, the dignity of the babies was violated, with one baby being “inadvertently disposed of as clinical waste by laboratory staff after her postmortem examination”.
When the report was published last month, I issued a joint statement with local MPs expressing our deepest sympathies with the harmed and bereaved families, and our ongoing commitment to them. Yet truthfully, it feels impossible to put into words the scale and impact of these failings, or the strength of the families devastated by them. These are people who had already endured the unbearable and then had to relive their worst trauma in the pursuit of truth and accountability. Having met some of the affected families over the years, I can say that their courage in the face of such injustice is remarkable, and it is thanks to them that such a landmark report now exists. Nothing can undo the harm that was inflicted on them, so these families have undertaken the ultimate selfless act in fighting for change for future patients.
Behind each number is a future grieved and an entire family that will never be the same again. People were utterly failed, often repeatedly, by the services that were supposed to care for them in some of their most vulnerable moments
I also want to pay tribute to Michelle Welsh, the MP for Sherwood Forest, who has tirelessly campaigned for improvements in maternity services for six years, after her own traumatic birth experience which put her and her baby’s lives at risk. In May, she was appointed as the government’s first national Maternity Adviser, and now sits on the National Maternity and Neonatal Taskforce. She has already brought enormous lived experience, passion and empathy to this vital role.
The painful reality is that Nottingham is not an isolated case when it comes to failings in maternity services. Donna Ockenden has already begun her next review into Leeds Teaching Hospitals NHS Trust, which will be the fifth major maternity inquiry in a decade, after Morecambe Bay, Shrewsbury and Telford, East Kent and Nottingham. In Leeds, at least 56 baby deaths and two maternal deaths have been reported as potentially avoidable. The Hillsborough Law, expected to come into force this autumn, will impose a duty of candour on staff, so senior clinicians will be compelled to give evidence in any future maternity review, and will not be allowed to dodge scrutiny as many did in Nottingham.
A national report, led by Baroness Amos and published just a week after the Ockenden review, concluded that women and babies across England are being failed “on a scale that shames our society”.
Shockingly, it found that the rate at which mothers die during childbirth is 20% higher than it was in 2009-11, when the government set an ambition to halve the rate of maternal mortality in England, and that many maternity wards are falling short of the required standards, with inspections finding that over a third need improvements. The UK is also falling behind internationally. A 2022 study concluded that our maternal mortality rate is the second-highest in Europe, with UK mothers being three times more likely to die around the time of pregnancy compared with those in Norway.
These failings are also compounded by inequalities – Black women are almost three times more likely than white women to die during or shortly after pregnancy, and women in the most deprived areas face twice the risk of those in the wealthiest. Donna Ockenden’s review of Nottingham’s maternity services also found that women who were most likely to have their concerns dismissed or minimised were those from Black, Asian and other minority ethnic backgrounds, those living in deprived areas, those with mental health needs, and those who did not speak English as a first language.
It is abundantly clear that the government must urgently improve maternity services in Nottingham and across the country. One of my constituents, who was included in the Nottingham review, summed up well where we go from here when she told the Health Secretary that “we need immediate action and we need long-term accountability.” When report after report is saying the same thing – that we need more investment into our maternity services, and hospitals in general; we need to get rid of the toxic culture that allows bullying, racism and discrimination to fester; and we must listen to women as a matter of clinical safety – there are no excuses for inaction, especially when we live in an age when medicine has never been more advanced.
In Nottingham, alongside local MPs, I have vowed to do everything in our power to hold NUH and the regulators to account, and to ensure that Donna Ockenden’s recommendations are implemented in full. I support calls for a public inquiry, provided that it does not delay criminal proceedings, and I have been clear that this also must not become an excuse to postpone action. We must ensure that the babies and mothers disabled by the harm they suffered at Nottingham University Hospitals can access the support and services they need throughout their lives, including high-quality SEND education and social security payments that don’t force them into hardship. Nationally, I will keep pushing for the investment and staffing our NHS needs and for an end to the inequalities in maternity and neonatal outcomes.
Bringing a child into the world should never be an experience defined by fear and harm. No family should have one of the happiest moments of their lives turn into an avoidable tragedy. We must work towards ensuring that high-standard, compassionate maternity services are a guarantee for everyone.
We have a favour to ask
LeftLion is Nottingham’s meeting point for information about what’s going on in our city, from the established organisations to the grassroots. We want to keep what we do free to all to access, but increasingly we are relying on revenue from our readers to continue. Can you spare a few quid each month to support us?
